Inspection on 19/07/05 for Westwood

This inspection was carried out on 19th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Westwood 16/11/07

Westwood 22/08/06

Westwood 15/11/05

Westwood 17/05/05

Westwood 02/02/05

Westwood 14/10/04

Westwood 03/03/04

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Maple Lodge

Heathlands

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Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Westwood 284 Bath Road Worcester WR5 3ET Lead Inspector Yvonne South Announced 19 July 2005 09:40am The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Westwood E52 S18697 Westwood V233935 190705.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Westwood Address 284 Bath Road, Worcester WR5 3ET Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01905 353866 Mr Anthony Harold Downer Mrs Zinnat Esmail Downer Mr Anthony Harold Downer Care Home 12 Category(ies) of OP Old Age (12) registration, with number of places Westwood E52 S18697 Westwood V233935 190705.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: There are no conditions of registration in addition to those recorded on the previous page. Date of last inspection 17 May 2005 Brief Description of the Service: Westwood is a modern bungalow with an extension at the rear. The home is situated on a main road out of Worcester City, conveniently sited for local amenities and transport. There is a small parking area at the front and a large attractive level garden at the back. There are eight single bedrooms six of which have en-suite facilities, and two double bedrooms one of which has an ensuite facility, communal toilets, bathrooms, dining room and three lounge areas. In addition there is a spacious furnished veranda opening onto the garden. Everywhere is well maintained and furnished in a comfortable homely manner. The registered owners, Mr and Mrs Downer, own and manage the home and offer a service for a maximum of twelve people of either sex over the age of sixty five years who have mild to moderate needs associated with old age. Westwood E52 S18697 Westwood V233935 190705.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is based on a routine announced inspection that commenced at 09:40am and took place over 4 hours. Assistance was given by the manager/owners. The inspection focused on the standards relating to the requirements and recommendations that had arisen out of the two previous inspections. The inspector spoke to two service users, assessed one person’s care records and several other documents, policies and procedures. What the service does well: What has improved since the last inspection? A large amount of work had been undertaken to improve systems and safeguards for the people that live in the home. Individuals had a plan of the care they needed, staff received regular support and guidance from the owners and a system had been developed that enable standards to be monitored and quality maintained. Staff had received training in fire safety and food hygiene. Westwood E52 S18697 Westwood V233935 190705.doc Version 1.40 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Westwood E52 S18697 Westwood V233935 190705.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Westwood E52 S18697 Westwood V233935 190705.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,3 Information is given verbally to enable a person to make a decision on their admission to the home. Written information is not available to support statements made. People are only admitted to the home if an assessment identifies that the home can meet their needs within its registration category. EVIDENCE: Two requirements were made on 14.09.04 relating to the content of the Statement of Purpose and the Service Users’ Guide. Drafts of the amended documents were taken during this inspection and assessed. These, broadly speaking, addressed the requrements of the legislation and the National Minimum Standards. However advice has been given regarding amendments to these two documents and the Agreement of Care, that need to be carried out before the documents are finalised. Westwood E52 S18697 Westwood V233935 190705.doc Version 1.40 Page 9 A requirement was made in the previous report relating to the content of preadmission assessments. The format in use provided a facility to record information related to the topics listed in standard 3.3 with the exception of oral health and foot care. Space for entries was limited in some areas. The assessment documents for one person were inspected. They were supported by the documentation received from the person’s previous residence and the compilation of information, although lacking in detail, was acceptable. The service user concerned confirmed that the home was fully able to provide the care she needed. Westwood E52 S18697 Westwood V233935 190705.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9 Assessments and care plans should be recorded in greater detail so as to advise and guide staff in the performance of their duties. Medication storage needs to be assessed to ensure that it meets current standards in relation to security. EVIDENCE: Requirements were made in previous reports relating to service user plans. One plan was assessed during this inspection. Appropriate information was recorded, although more detail needed be included to advise and assist staff in their work. Risk assessments had been carried out relating to falls. Care plans had been reviewed and relatives had been involved if service users were unable to contribute. Documents were dated and signed. Westwood E52 S18697 Westwood V233935 190705.doc Version 1.40 Page 11 A brief assessment had been undertaken in relation to pressure areas. Although the risk to the individual in this case was considered to be low the assessment tool would benefit from further development to enable more evidence to be gathered and considered on which to base a conclusion. Only one person in the home was considered to need special pressure care equipment and this had been provided. Health care history was well documented. Daily records were well maintained and a separate record of health care matters was kept for quick easy access. Professional advice was sought regarding continence matters but the service was considered by the proprietor to be slow. Mental and physical health was well monitored. This was evidenced in the daily records and confirmed by service users. Limited information was obtained regarding nutritional screening. However likes, dislikes and allergies had been noted. Weights had been monitored. Ancillary health care services were obtained for service users. Medication records had been acceptably maintained. Two people were trained and authorised to administer medication. One or other was always on duty to undertake to the task. None of the current service users managed their own medication independently. A service user told the inspector that she was happy for the home to take the responsibility from her. Medication was stored in a locked cash box in the fridge and in a secure wooden cupboard in the dining room. There was no controlled drugs storage. The pharmacy inspector will be asked to visit and advise. The pharmacist from Boots The Chemist had visited and found the storage acceptable. Westwood E52 S18697 Westwood V233935 190705.doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These standards were not assessed during this inspection. EVIDENCE: Although these standards were not assessed it was pleasing to observe that service users were joining in a session of music and movement during the morning and talked of the event with some animation later when they had their mid morning drinks. Photographs were seen of service users enjoying themselves at social functions and of an individual doing some gardening (planting of seeds). A service user said how happy she was in the home and how much she enjoyed the garden and being able to ‘dabble’ with supervision and support. She and her friend confirmed that they had recently moved in from another home and considered that they had settled well and were well cared for. Friends and family members visited them and they were having their own private telephones fitted in their rooms. They were ‘very happy and the care was wonderful’. Westwood E52 S18697 Westwood V233935 190705.doc Version 1.40 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, Staff need to receive training to enable them to recognise and respond appropriately to concerns relating to abuse. EVIDENCE: Procedures to advise and guide staff in the Protection of Valuable Adults were available. Training had not been undertaken, as the course that the manager had applied to attend had been over subscribed. A repeat of the course is now awaited. Staff had been advised how to respond to people who demonstrated physical and/or verbal aggression. Westwood E52 S18697 Westwood V233935 190705.doc Version 1.40 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These standards were not assessed during this inspection. EVIDENCE: Westwood E52 S18697 Westwood V233935 190705.doc Version 1.40 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 29,30 Service users are protected by the recruitment process that is used. Training provides staff with knowledge that assists them to deliver acceptable care. EVIDENCE: The home operates an acceptable recruitment procedure. It was confirmed that two references were taken up on prospective staff and CRB and POVA checks were made. Copies of the GSCC code of conduct and practice had been supplied to all except the last two people to be appointed. Their copies would soon be obtained. Staff were employed on a trial basis. Permanent contracts were only issued on the successful completion of at least six weeks employment. Individual training records were not fully assessed during this inspection. However a training analysis/plan was seen. A plan for this year was being developed. Full information regarding induction and foundation training was available and a check list for trainer and trainee to sign and date. All staff had been trained in Food Hygiene and two will undertake refresher courses in the near future. Westwood E52 S18697 Westwood V233935 190705.doc Version 1.40 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,36, Systems and procedures monitor and ensure staff are supported and service users receive an acceptable standard of care. EVIDENCE: A good Quality Assurance System was seen and the questionnaires that had been developed to support it. This system had been successfully piloted and it was now proposed to fully implement it. An annual development plan was not available for the home. It was said that decisions and short-term plans were made and executed according to the priorities at the time. Policies and procedures were available but somewhat dispersed in the office. They were being collected into a manual for the staff to consult when required. Westwood E52 S18697 Westwood V233935 190705.doc Version 1.40 Page 17 Fifteen requirements and two recommendations had been set in the previous inspections. It was acknowledged that a great effort had been made prior to this inspection and there had been compliance with most requirements. The new systems and standards must now be fully implemented and maintained. A supervision system had been set up and all staff had received supervision in June this year. Records had been maintained. All staff received fire safety training from an external trainer in June this year. Internal fire safety training must take place with all staff every three months. It was advised that in addition to the individual training records a monitoring tool be developed to ensure everyone received training at the appropriate frequency and participated in at least one fire drill each year. Westwood E52 S18697 Westwood V233935 190705.doc Version 1.40 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 2 x x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 2 x x 3 x x 3 x x Westwood E52 S18697 Westwood V233935 190705.doc Version 1.40 Page 19 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1, 2 Regulation 4(1)(c) Requirement A Statement of Purpose, Service Users Guide and Agreement of Care, that meet the requirements of the legislation and National Minimum Standards, must be available. Copies must be sent to the Commision for Social Care Inspection within the timescale set. Staff must receive training in relation to the protection of vulnerable adults, the homes relevent policies and procedures and local protocols Timescale for action 31st September 2005 2. 18,30 12(1), 13(6) 31st December 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Westwood E52 S18697 Westwood V233935 190705.doc Version 1.40 Page 20 Commission for Social Care Inspection The Coach House, John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Westwood E52 S18697 Westwood V233935 190705.doc Version 1.40 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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